3 - Uncertainty in Medicine: Through Thick and Thin
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What is the main topic discussed in this episode?
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The first time I felt like something was wrong was literally a month after I'd had the replacement done.
This is Dana. In 2021, she underwent a total knee replacement on her left leg. A pretty run-of-the-mill procedure. Around 850,000 are performed every year in the US.
I knew it would be painful, I knew it would be tiring, I knew it would be swollen, I knew it would start feeling better slowly, I knew the incision would heal. And very few of those things happened.
This is the Nocturnus, Uncertainty in Medicine. I'm Emily Silverman. Dana went into her knee surgery hoping that it would ease her chronic pain. Instead, it marked the beginning of a medical mystery. Diagnostic uncertainty is one of the hardest parts of medicine. Some patients find answers quickly, but others, like Dana, embark on a diagnostic Odyssey. A prolonged journey where it's clear that something's wrong, but no one can figure out why. Today we're talking about uncertainty, diagnosis, and the role of primary care. why it's so much more than just a gatekeeper to specialists, and why fewer and fewer doctors are choosing it. Later, we'll look at a small but powerful change that one residency program made to help fix that.
But first, Dana.
Some of the main things that were wrong that were like alarming to me were how long it was taking for the incision to heal, that it just wouldn't close. There were just so many markers that I wasn't meeting, walking, standing, being able to straighten my leg. Pain. I'd gone back to the PA multiple times, either via messages on my chart, phone calls, visits in the clinic, and it was all just everybody heals differently, things take time. It was just nobody's listening.
And so Dana went to the one person she knew would listen to her, her primary care doctor, Doctor Sarah Hartfelt.
I've known Dana for close to fourteen years. We met more frequently than the once-a-year nice to see you kinds of primary care patients.
The average primary care doctor in the US manages a panel of 2,300 patients. Of those patients, many only come in for checkups or refills, but others are complex and require more regular visits.
You know, if you have diabetes, I'd like to see you at least every three to six months. And then in any given time, there are probably six to twelve people that are kind of on the front burner. That I am thinking about, worrying about did they ever go see that specialist I wanted them to go see? Are those results back
and Dana was now one of those front burner patients. The redness, the swelling, the failure of the incision site to close. All of it was pretty worrisome to Dr. Hartfelt.
Initially we could not figure out why she seemed to be having some kind of an allergic reaction all around the incision site. And the fear after surgery is infection, that something has gotten infected. And when you've put new hardware into a joint, if infection gets into hardware, everybody gets terrified. So there was initially a very aggressive approach by the orthopedic surgeons. She made at least one or two trips to the ER and then me. How do we make sure that this isn't infected? Is it infected?
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Chapters
5 chapters
1
What is the main topic discussed in this episode?
0:00–4:41
2
What happened to Dana after her routine knee replacement?
4:41–13:48
3
How did primary‑care doctor Sarah Hartfelt become Dana’s advocate?
13:48–20:24
4
Why did doctors suspect an infection and how was it ruled out?
20:24–23:18
5
Could a nickel allergy be causing Dana’s systemic symptoms?
23:18–31:58